Registration Form Fourth Annual QMP Reconstructive Surgery Symposium November 19-21, 2010 at The Ritz-Carlton St. Louis, St. Louis, MO Name: __________________________________________________________ Address: ________________________________________________________ City: ________________________________ State: ______ Zip: __________ E-mail: ____________________________ Country______________________ Telephone: __________________________ Fax: _______________________ REGISTRATION FEES & DEADLINE       BEFORE 7/7/10     BEFORE 11/19/10     AFTER 11/19/10      Physician     $950     $1050     $1250      Resident/Fellows     $600     $700     $800 MAKE CHECKS PAYABLE TO: Quality Medical Publishing, Inc. Send your registration form to: Quality Medical Publishing, Inc. 2248 Welsch Industrial Ct. St. Louis, MO 63146 USA Attn: Andrew Berger OR Fax your registration and credit card information to: (314) 878-9937 CANCELLATION POLICY: Registration is 50% refundable only if a written cancelation is received at QMP before October 19, 2010. No refunds will be given after October 19, 2010 for any reason. Payment (check one): Credit Card:   Discover   Visa   Mastercard   American Express Check Enclosed Card #: ____________________________ Exp. Date: ______ Verification #: _____ Print Card Holder's Name: _____________________________________ Signature: ____________________________________________________